AAOS Letter to CMS Administrator Seema Verma
William J. Maloney, M.D., President of AAOS, raised five concerns to CMS Administrator Seema Verma in a letter to her. He said:
- Precedence to comprehensive care for joint replacement (CJR) over BPCI Advanced could limit the participation of independent physicians and their ability to participate in BPCI would be outside of Lower Extremity Joint Replacement (LEJR) episodes.
- The policy could hurt the physician-patient relationship, as it will disrupt the Medicare beneficiary’‘s Lower Extremity Joint Replacement LEJR care that will be moved to the hospital from the physician. This can lead to reduced participating physician group practice engagement.
- The policy is built on payment of performance on 32 clinical episodes.
- The initial application is too complex and burdensome for smaller practices with limited resources and capabilities.
- CMS has not clearly delineated the requirements of this policy implementation. This lack of clarity from CMS will lead to defaulting all TKA [total knee arthroplasty] procedures to outpatient status which would affect the CJR, BPCI and BPCI Advanced models.
AAOS is concerned that this move will be too risky for medically complex cases and high comorbidity patients, who need hospitalization.
What the Data is Showing So Far?
The Lewin Group authored a report—“CMS Bundled Payments For Care Improvement Initiative Models 2-4: Year 3 Evaluation and Monitoring Annual Report October 2017” which quantified the effect that bundled payment programs had on Medicare costs and quality of care.
According to their study, the Lewin Group authors wrote that the average decline in costs between October 2013 and September 2015 was $1,105 per case in non-fracture episodes. Importantly, the researchers found that there was no change in quality despite the lower costs.
It should be noted, however, that the study was limited to only hospital participants.
The Lewin Group also reported that physician group practices (PGP) realized LEJR cost savings of $3,214 or 15% per episode as compared to the 2009-2012 historic baseline period.
We also learned at the AAOS seminar that other groups had documented $12.6 million in savings at 40 CJR hospitals from 3Q2016 to 2Q2017.
AAOS shared data at the seminar which compared the effects of BPCI on physician groups versus acute care hospitals. The result? Physician group practices performed much better than acute care hospitals under the bundled care model.
Going Forward
AAOS and other specialty and state societies are clearly raising the alarm about CMS’ body language in favor of an outpatient model. CMS, says AAOS and its affiliated societies, should do more to protect Medicare beneficiaries.
Specifically, CMS should remove TKA from the outpatient setting or, at the very least, establish evidence-based outpatient inclusion and exclusion criteria for patients.
Finally, AAOS in its letter to CMS Administrator Verma called for clarity and timely details on benchmarking and target pricing.
